Crew Resource Management

An application for the fire service

Carr Boyd and Rob Cannon
04/26/2010 -

The evolution of the public sector and the limitations of scarce resources increasingly require fire departments to provide more with less. The unintended side effect of this situation is that as fire service practitioners are overloaded with more responsibilities and tasks to maintain proficiency, the probability of error, inefficiency, and undesired outcomes rises. The human organism can be proficient in only so many things.

As Malcolm Gladwell explains in his book, Outliers: The Story of Success, the average person requires about 10,000 hours of study and practical experience to become an expert at any one specialty. If these numbers are extrapolated based on the primary disciplines for which firefighters are expected to maintain proficiency (fire suppression, rescue, EMS, etc.), the average firefighter will retire well before he or she can become a skilled practitioner.

Why CRM training?

The reality is that even the most capable people only ever master one or two things at an expert level during their lifetime. In addition, the limitations of individual decision-making capabilities become more pronounced as stress increases. Therefore, not only are individuals limited when overloaded with information, but their ability to then manage that information and make good decisions further regresses under conditions of stress, which are common in the environments to which firefighters are frequently exposed.

The implications for the fire service are that as individuals we are susceptible to errors and ineffective service delivery that can only be overcome by facilitating highly effective teams, as “teamwork lowers tasks complexity,” says K.E. Weick in The Vulnerable System: An Analysis of the Tenerife Air Disaster.

The airline industry, which struggled for decades to reduce crashes caused by pilot error, developed a highly effective training program, crew resource management, aimed at reducing the incidents of human error in the cockpit. This program is particularly applicable to the fire service.

Like the fire service, the airline industry is hierarchical with a culture that insists on deference to higher ranking or more senior personnel. Many airline crashes, where the cause was deemed human error, have been attributed to this culture, where subordinate flight crew members showed great deference to the captain, rather than making their concerns known.

This was evident in the crash of a DC-8 bound for Portland, Oregon in 1978 with 173 people on board. While approaching the runway, an indicator light warned that the front wheels were not locked into place. The captain had the crew check the fuses, replace the warning light, and run through a myriad of other checks while circling high above the airport. Not long into the process of trying to sort out the landing gear issue, the flight engineer commented to the captain in a roundabout manner that the plane was low on fuel. This warning was dismissed, or simply ignored by the captain, who was singularly focused (i.e. tunnel vision) on the landing gear and did not want to be bothered. It was not until the engines began to stall as the fuel tanks ran dry that the captain’s attention turned and he was forced to crash land the plane into a suburban area of Portland. An NTSB investigator later commented “that the captain was a real S.O.B.”

This is just one of many examples of human error and poor communication among flight crews that ultimately led to catastrophic outcomes in the airline industry. Since the 1990s the number of human error-related crashes has significantly declined, which empirical evidence suggests is linked to the introduction of crew resource management (CRM) training.

Prior to the 1990’s, crash investigation reports repeatedly documented a lack of effective communication between flight crew members as the number one contributing factor to not recognizing, and then stopping, the chain of errors that frequently preceded these incidents As with most catastrophic situations, many small events finally culminated in one major incident that could have been avoided if one of the smaller events had been recognized and resolved. In many cases, subordinate members of the flight crew recognized the impending problems, but either failed to communicate their concerns to the captain or delivered their message in such a way that it was easy to ignore.

For example, the 1977 runway incident between Pan Am Flight 1736 and KLM Flight 4805 in Tenerife involved a long chain of events and errors that culminated in a horrific collision. In this situation, fog had settled in, lowering visibility and preventing the KLM pilot from seeing the Pan Am plane taxiing up the runway. As the KLM plane prepared to accelerate down the runway, the co-pilot advised the captain that they had not been cleared for take-off. The captain, who was a flight instructor and KLM’s lead pilot, snapped at the co-pilot, who radioed the tower, but again did not receive clearance. Despite the lack of clearance to take-off, the KLM captain throttled the engines to full power in a rush to get the flight back on schedule. Not wanting to contradict or challenge the captain’s authority, the co-pilot sheepishly asked, “Did he [Pan Am plane] not clear the runway, then?” This communication failed to reiterate that clearance to take-off had not been received or that the co-pilot believed the Pan Am jet was still on the runway, so the captain continued on with the take-off sequence. Halfway down the runway the KLM and Pan Am planes collided killing 583 people.

Parallels between the airline industry and the fire service are prevalent, not the least of which is the propensity for both pilots and firefighters to be overloaded, fatigued, and stressed when decision-making is at its most critical points. This is important to consider because, “As stress increases, perception narrows, more contextual information is lost, and parameters deteriorate to more extreme levels before they are noticed, all of which leads to more puzzlement, less meaning, and more perceived complexity,” according to Weick.

When humans are confronted with chaos and unpredictable conditions error becomes much more likely, regardless of experience, because we are fallible. One would like to think that a more experienced practitioner would be less prone to making mistakes, but this is not necessarily true as was seen with the highly experienced KLM pilot.

Hierarchy

In reviewing incidents where firefighters have been injured or killed, human error is often the main contributing factor. Like many of the plane crashes, firefighter injuries and deaths are often preceded by a chain of small events that go unrecognized or unreported, thus preventing the chain from being broken. The endemic issues associated with hierarchy, such as a reliance on vertical communications and centralization of decision-making, which inhibited flight crew operations are similar to those found across the fire service.

Officers at all levels often make it known through their actions, or other means, that “what they say goes and they do not want to be questioned,” which makes subordinates less likely to communicate their observations or concerns.

This attitude can be dangerous when objectively assessing the limitations of the human organism whose decision-making aptitude is significantly decreased as stress and fatigue mount. With the myriad of disciplines at which firefighters must be proficient and deliver at a moment’s notice under highly dynamic circumstances, it is neither reasonable nor rational to believe that an individual on his/her own can consistently make good decisions. This makes the ideals of CRM particularly applicable to the fire service, where we too have the luxury of working in teams.

Teamwork

However, the benefits that can be derived from a team are nullified if the knowledge and expertise of the members on that team are subordinated to one person’s views when decisions must be made. This is not to say that the time to sit down and have a debate is while searching a building in low visibility/high heat conditions, but facilitating an environment that encourages team members to speak up when they recognize a threatening condition that others seem to have missed. This is a sign of effective leadership.

Officers must know themselves, know their people, and know their stuff, to facilitate such team dynamics, which requires a significant amount of work and commitment. CRM is not about the officer in-charge subordinating his/her decision-making or responsibility to others on the team; it is simply an effort to open up communications to reduce errors by taking advantage of all the team member’s knowledge and viewpoints.

A downfall of any team is what Weick terms pluralistic ignorance, which occurs when a member of a team/group is confused or puzzled about a situation but assumes that the others on the team, who may be more senior, have more experience, or have a higher rank, are not. Under such conditions, the team member likely does not point out the potential problem, which goes unrecognized and potentially becomes one of the small events in a long chain that ultimately leads to catastrophe.

Trust

Effective teams often thrive under conditions of stress, where the individual over time may become ineffective. To facilitate the development of such teams, “...leaders must create a climate in which trust, doubt, openness, candor, and pride can co-exist and be rewarded,” according to Weick. This places an emphasis on strong leadership abilities, where the leader is willing to trust subordinates and encourage team members to question decisions in an effort to break the chain of errors that so often precede a catastrophic event.

Recognizing a problem or error can be relatively easy if personnel are well trained and trust one another. The real challenge is in finding the courage to take action to break the chain of errors. This is particularly difficult in a culture of pseudo aggressiveness that permeates much of the fire service, where it is far more acceptable to push forward than it is to pull back; however, many a catastrophic event could have been prevented if someone had the courage to speak up and a leader had the intestinal fortitude to pull back or reevaluate the situation.

Carr Boyd is currently a Captain with the Charlotte Fire Department, an Adjunct Faculty member at the University of North Carolina at Charlotte in the Political Science and Fire Safety Engineering Programs, and serves as an affiliate with Academy Leadership, LLC delivering leadership programs for public and private sector organizations. Rob Cannon is currently a Captain with the Charlotte Fire Department and serves as an affiliate with Academy Leadership, LLC delivering leadership programs for public and private sector organizations. He is a graduate of the United States Naval Academy and holds a Master of Public Administration degree.